Do Not Resuscitate Status in Critically-Ill HIV Patients
CCCF ePoster library. Gregory A. Oct 2, 2017; 198153
Anne Gregory
Anne Gregory
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Do Not Resuscitate Status in Critically-Ill HIV Patients

Gregory, Anne1; Turvey, Shannon2; Bagshaw, Sean1; Sligl, Wendy1,2

1Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; 2 Division of Infectious Diseases; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

 


Introduction: HIV care has been revolutionized over the last decade with combination anti-retroviral therapy (cART). Epidemiology and a survival analysis of critically ill HIV positive patients in the Edmonton zone has been recently published; however, limitations in support in this patient population has not been previously examined.

Objectives: To identify predictors of do-not-resuscitate (DNR) status in critically ill HIV-infected patients admitted to the Intensive Care Unit (ICU) in the era of cART.
 
Methods: Retrospective cohort study of all first-time admissions of HIV-infected patients to five ICUs in Edmonton, Alberta from July 2002 to July 2014.  Data collected included d
demographics, comorbidities, markers of HIV disease severity and control, admission diagnoses, severity of illness, organ failure, DNR status and support withdrawal.  Multivariable logistic regression analysis was performed to identify factors associated with DNR status.
 
Results: During the study period, there were 282 patients admitted to the ICU for the first time. Mean (SD) age was 44 (±10) years, 169 (59%) were male, 134 (47%) aboriginal, 153 (54%) co-infected with hepatitis C virus, and 184 (65%) had a history of polysubstance use.  Median (IQR) CD4 count and viral load were 125 (30-300) cells/mm3 and 28,000(110-27000) copies/mL, respectively. Only 98 (34%) patients were receiving ART at the time of admission while 45 (16%) were newly diagnosed in the ICU. The most common admission diagnosis was sepsis (63%); 213 (75%) received mechanical ventilation, 133 (47%) vasopressor support and 35 (12%) renal replacement therapy. Sixty-seven (24%) patients had DNR status and support was withdrawn in 37 (13%). In multivariable analysis, APACHE II score (odds ratio [OR] 1.13; 95% CI, 1.08-1.19, p<0.001), coronary artery disease (CAD) (OR 5.70; 95% CI, 1.18-27.76, p=0.031), prior opportunistic infection (OR 2.59; 95% CI, 1.20-5.57, p=0.015) and duration of HIV infection (OR 1.07 per year; 95% CI, 1.01-1.14, p=0.025) were independently associated DNR status. Other factors such as ethnicity, HIV risk factor(s), CD4 count and viral load were not associated with DNR status.
 
Conclusion: In this relatively young cohort of HIV infected patients, one in four patients had DNR status during ICU admission. Severity of illness appeared to be a strong predictor of DNR designation, along with CAD, prior opportunistic infection, and duration of HIV infection. Future work should characterize the timing of patient DNR orders relative to ICU admission and describe patient and provider-specific factors that may influence decision-making towards DNR status.

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